Provider Demographics
NPI:1083817415
Name:CUBILLAN, MARY JOY (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY JOY
Middle Name:
Last Name:CUBILLAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7527 JEREZ CT UNIT E
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-7449
Mailing Address - Country:US
Mailing Address - Phone:347-208-3338
Mailing Address - Fax:
Practice Address - Street 1:5576 FOXTAIL LOOP
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92010-7152
Practice Address - Country:US
Practice Address - Phone:347-208-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07341GMedicare ID - Type Unspecified
NYQL717ZVTQ1Medicare PIN